How Obamacare could spark the brain drain of physicians from the developing world.

By Kate TulenkoKate Tulenko, M.D., MPH, MPhil, is deputy director of CapacityPlus, the U.S. Agency for International Development's program addressing the global health workforce shortage. Any opinions expressed are solely those of the author and do not represent those of any partner.

June 11, 2010

Forget about all the members of Congress who are supposedly about to suffer from "Obamacare" blowback in the mid-term elections. Forget about the deficit, the bureaucracy, and any other critiques you might have heard about President Barack Obama’s health-care reform passed earlier this year. There’s a far bigger consequence looming abroad: U.S. health-care reform will exact an excruciating cost on the developing world. Here’s why: Tens of thousands of doctors are about to leave their home countries — where they are often desperately needed — to come to the United States to meet America’s growing demand.

That’s right: America is about to induce massive medical brain drain. The historic passage of health-care reform legislation in March will provide an estimated 32 million uninsured Americans with health insurance. But the United States will need to rapidly grow its supply of doctors and nurses to meet the demand that creates — a fact that will surely attract qualified doctors and nurses to America’s higher salaries, better working conditions, and promise of a booming industry. There’s nowhere for those health professionals to come from but overseas; the domestic education system simply won’t produce enough. Enter brain drain.

Even now, the United States relies heavily on foreign-trained health-care workers. A full quarter of practicing physicians in the United States and 28 percent of U.S. medical residents come from abroad. Of these, 25 percent were trained in India and Pakistan, countries with health-worker crises so acute that the World Health Organization includes them on its list of countries with a "Human Resources for Health crisis." Each country has a mere 1.13 doctors per 1,000 inhabitants, while the United States enjoys 13.22 — one of the highest ratios in the world. Other developing countries have already lost more than half their physicians to the United States. There are more Ethiopian physicians practicing in Chicago today than in all of Ethiopia, a country of 80 million and Africa’s second-most populous country. Put otherwise, the United States is importing health workers from countries where polio still kills and paralyzes children. It is, in a word, unconscionable, and Obama’s health reforms will only make things worse.

Why does the United States need so many foreign doctors? In part because the country’s medical and nursing schools are turning away tens of thousands of qualified applicants for lack of places and funding to accept and train them. Theseyoung Americans are forever shut out of six-figure jobs in one of the country’s fastest growing and arguably most socially rewarding sectors. Reversing this trend would take years of building new medical schools, particularly in areas where there is already a shortage of doctors. Meanwhile, demand is simply growing faster than the supply of homegrown doctors and nurses.

Look no further than Massachusetts and its experience with health-insurance reform to see why U.S. demand for foreign health workers will increase. The state’s health-care bill brought an additional 340,000 people into the insurance system, and demand for health-care workers subsequently rose beyond capacity. Waiting times for new-patient appointments with an internist increased 58 percent — from 33 days to 52 days — and half of Massachusetts’s primary-care practices closed their doors to new patients, the highest level ever recorded. Massachusetts, one of the U.S. states with the highest number of primary-care physicians per capita, experienced these shortages upon expanding its insured population by only 5 percent (by comparison, most predictions say that U.S. health-care reform will increase the number of insured nationwide by a whopping 12 percent).

Even measures in the health-care bill meant to boost the population of domestic physicians might do more harm than good. Congress has proposed providing funding to increase the number of U.S. residency positions by 15,000 to meet the anticipated increased demand for doctors. Yet these bills do not increase the number of medical-school slots. So those added residency positions will have to be filled by more than doubling the country’s annual importation of foreign-trained doctors.

The apparatus to bring in these overseas professionals is well oiled, with no consideration for the potential impact of an immigrant’s exit from his or her country of origin. Nurses are drawn to American soil through a well-organized, billion-dollar, private-firm-based nurse recruitment industry. Physicians tend to either apply directly to the U.S. National Residency Matching Program or be recruited by residency programs or immigration lawyers. Despite consistently being among the highest paid professionals in their homelands, foreign doctors are drawn to the United States by the pull of even higher salaries and better training and facilities.

But though the prospects for emigrating physicians might be good, the consequences for the countries they leave behind are grave. Mortality rates for infants, children, and expectant mothers are especially sensitive to health-worker shortages, with child mortality tripling as communities go from five health workers per 1,000 population to less than one per thousand, according to a 2004 Rockefeller Foundation report.

Medical brain drain affects education systems, too. Only the best and brightest can pass the U.S. certification exams, meaning that those who emigrate are often top university professors. A recently released study funded by the Gates Foundation found that migration to wealthier countries is the No. 1 cause of loss of African medical school professors — accounting for a full 25 percent, with most going to the United States. Not surprisingly, the same study also revealed that lack of professors was one of the main barriers to training more health workers in Africa.

Even in the absence of health reform, brain drain was destined to be a growing problem for poor countries. According to studies by the U.S. Bureau of Health Professions and the Association of American Medical Colleges, conducted before the passage of health-care reform, the aging U.S. population would have needed at least 40 percent more primary-care providers by 2020, and the United States would have experienced a shortage of 124,000 physicians by 2025. With little chance of the United States meeting that demand domestically, it’s likely the needed nurses and doctors will come from abroad.

Ironically, while the United States is recruiting thousands of doctors to its shores each year, it is simultaneously spending billions trying to build health systems in precisely the countries whose physicians it is stealing away. In recent years, major U.S. overseas development programs have failed to meet their goals due to a lack of health workers, and funding has started pouring into training in this sector. But what’s the point, if those same doctors will later just be recruited away?

The answer is clear: Until the United States is self-sufficient in the education of its own health workers, it will continue to risk the health of the most vulnerable people in the United States and abroad. The Obama administration has made a major commitment to improving the health of the poorest people in the world through the $63 billion Global Health Initiative. But much of this effort will be wasted if the United States continues to take from developing countries the very thing health systems need most: the people needed to run them.